P - 84634REQUEST FOR ELECTRICAL INSPECTION � �:�
4`+-�� 2 4 6 Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
' / Phone (612) 642-0800
� Home Duolex Aot. Blda. Other: New Addn
Commercial Indusfrial Farm ' Remoc
Air C�nd. Htg. E ui . Water Hfr. Load Mgmt. Other:
Dry ng ( Elec. Heat Temp. Service
"X" above the work covered y this request. Enter remarks in this space and on the back of the white copy
Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall to 00 Amps � 0 to 100 Amps
Sheet Lig./Tra(fic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR•s usE oN�r TO�L
$ign/Oudine Ltg. Xfmr. ��
Alarm/Remote Conhol
Swimming Pool
I hereb cerTi thaf I iqs the elechical installation deuribed herein on the ,l —`
Irripation Boom po„al,ao Da _
I Investigative Fee�/ !� � � I � � ����� ( � %D �5 / �/
THIS INSTALLATION MAY BE ORDERED DtSCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This raquest void 1 A monfhs from validation date printed in this box.
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�K � 4 4 8 2 4 6 9* PLEASE PRINT OR TYPE
Requesf D/ate �] �J Rough-in inspection required? Yes ❑ No Inspecfion Olher Than Rough-In: ❑ Ready Now ill Call
(�� /"� / (You must call the inspecfor when ready) Date Ready:
I, icensed contractor ❑ owner hereby request inspection of the above elechical work at:
Job Address (Street, Box Route No.� Ciy Zip Code
(�y�5 5 �er
Seclio� No. Township Name or No. Range No. Fire No. Coun �^
Phone No.
� �� .__.___
� � Conhacfor License No. Master Lic. No.
�pp'�''TH:� �"' �iMM
: �Contraclor or� PerFomiig IAAOIIaKon)
�or Owner Perf�ni� Ins141MfiE� 1 V ( � Phone No.